Diagnostic and Operative Hysteroscopy Enrique Cayuela Font, Tirso Pérez Medina
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1Diagnostic and Operative Hysteroscopy
Editors Tirso Pérez-Medina Associate Professor Senior Gynaecologist Universidad Autonoma De Madrid Santa Cristina University Hospital Madrid, Spain Enrique Cayuela Font Chairman Department of Obstetrics and Gynaecology Vic General Hospital Barcelona, Spain
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© 2007, Editors
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
First Edition: 2007
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Tirso Pérez-Medina
Enrique Cayuela Font
4
5Contributors 7Foreword
It is often said that the few people who have the privilege of experiencing memorable professors while training are not later blessed with good pupils during their practice. Fortunately, destiny has been generous with me and has given me both. It is an honour for me to write this introductory note for two magnificent co-workers and pioneers in the field of hysteroscopy, who, in this book, share their knowledge and extensive experience in this fast-growing and extensive field.
Without forgetting any of the solid, theoretical principles, the book is full of practical advice and much wisdom acquired from the many hours these authors have spent operating.
The iconography in this book is outstanding and the images seize the know-how of the technique of the authors. Due to their great experience they have personally contributed to the improvement of hysteroscopy equipment by sharing their ideas with the industry. Through some if their ideas, improvement of the optics involved in image capturing was achieved.
Thanks to their belief in this method, their enthusiasm and their teachings, they have helped spread the technique. At present, hysteroscopy is performed by many specialists that had in them their educational teachers.
While writing the foreword of this book on Hysteroscopy I cannot help but remember the days when I was head of OB and GYN at the old Red Cross Hospital in Madrid. I will coin a phase from King Phillip II, a XVII century Spanish King, to describe hysteroscopy in those days. When he spoke of the “Invincible Armada” he said it was a heroic act “fighting against the elements”. This was certainly true of hysteroscopy at its beginnings in our hospital system. The optics and the instruments were very basic and what was worse, there was constant opposition from the “old school” who thought that hysteroscopy was little more than a passing craze. Thanks to perseverance, and lots of hard work hysteroscopy has consolidated into an indispensable technique in Gynaecology and at present, the hospitals of both authors are reference centres for the practice and teaching of the technique in Spain.
I believe that this book will help give the readers, students, physicians or specialists a comprehensive overview of the present focus of diagnostic and surgical hysteroscopy and it is my hope that the readers will enjoy this book as much as I have.
Jose Manuel Bajo-Arenas
President of the Spanish Society of Gynaecology and Obstetrics
Chief of the Department of Obstetrics and Gynaecology
Autónoma University of Madrid
Santa Cristina University Hospital
Madrid, Spain
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9Foreword
The wish to look into the human body is as old as human history. The Talmud describes an instrument that was used to view the cervix. More than 2000 years old specula, with elegant decorative engravings, were recovered from the ashes of Pompeii.
In 1805, Bozzini described a technique of examining the interior of the urethra. He reflected the light from a candle with a mirror directing the rays along a metal tube. His ingenuity was rewarded by the medical faculty of Vienna by censoring him for “undue curiosity.” Desormeaux, almost 60 years later, fared rather better. He designed a functioning cystoscope; the Academie Imperiale de Medicine de Paris rewarded him with a share of the Argenteuil prize. In 1869 in Ireland, Pantaleoni used this scope to view the uterine cavity of a 60 year old woman complaining of vaginal bleeding and was able to identify polyps within her uterus. Nitze improved the instrument; in 1879 he replaced the cumbersome external, alcohol and resin fuelled lamp with an incandescent platinum filament sited on the distal tip of the cystoscope.
Strides in medicine frequently follow technical improvements and innovations. These two disciplines are synergistic and stimulate each other. Endoscopy in general greatly benefited from early technical innovations that included the development of the incandescent light bulb by Edison (1880); introduction of the “cold light” concept, a method of transmitting intense light by means of a quartz rod, by Fourestier, Gladu and Vulmière in France in 1952; and the same year, the application of fiberoptics to endoscopy by Hopkins and Kapani in England.
Although hysteroscopy preceded gynecologic laparoscopy, its utilization and acceptance lagged behind that of laparoscopy until the introduction of effective uterine distention media, which permitted proper visualization of the cavity.
In 1970 Lindemann introduced a system using pressurized carbon dioxide to distend the uterus, while the same year Edström and Fernström used high molecular Dextran for the same purpose. Despite these improvements, application of the technique, which at the time was purely diagnostic, remained limited. This was due to significant improvements in non-invasive imaging techniques such as ultrasonography, and the use of a vaginal transducer for the assessment of the pelvic organs. At the time, hysteroscopy was described as “a technique looking for an indication.”
Yet the impact of hysteroscopy in our specialty has been radical. This came about when hysteroscopy started to be used as a new mode of surgical access into the uterus. This revolutionized and greatly simplified many procedures that previously required a laparotomy and a hysterotomy to access the uterine cavity: lysis of severe uterine synechiae, metroplasty for septate uterus, excision of symptomatic intrauterine fibroids. These, after all, are common conditions; hysteroscopy has simplified these procedures and significantly reduced their morbidity. Direct access to the uterus led to the introduction of interventions such as endometrial excision and endometrial ablation that offer a less invasive, yet effective alternative to hysterectomy in the treatment of abnormal (dysfunctional) uterine bleeding refractory to medical treatment. It permitted the introduction of a simple technique of permanent tubal sterilization.10
All of this was made possible by further technical improvements and innovations. Improvement in lens systems resulted in the production of endoscopes of significantly smaller caliber and better optics. This evolution permitted hysteroscopy to be performed without anesthesia, which eventually led to the introduction of “office hysteroscopy.”
The introduction of the lightweight mini video cameras and high resolution television monitors permitted the surgeon and others assisting at the procedure to view the operative field in one or more television monitors and work in concert as a team. These developments, together with the production of new and better equipment and instruments, allowed these intrauterine procedures to be performed more easily, more quickly and with greater safety.
The advent of operative hysteroscopy has changed medical practice in the treatment of certain conditions. Bleeding from submucous fibroids and dysfunctional uterine bleeding refractory to medical treatment frequently led to a hysterectomy in the past. Today many of these cases may be successfully treated by hysteroscopic excision of the fibroids and endometrial ablation respectively, techniques that are much less invasive yet fairly effective. In medicine, as in life, nothing remains static. Hysteroscopic endometrial ablation is already being replaced by several new simpler endometrial ablation techniques. Called “global ablation” or (better) non-hysteroscopic ablation, these techniques appear to yield outcomes similar to those resulting from hysteroscopic endometrial resection or roller ball ablation. Quoting Arthur Schopenhauer “change alone is eternal, perpetual, immortal.”
The book is comprehensive, to the extent of including chapters on the “anatomy, histology, physiology and pathology of the endocervix and uterine cavity” (chapter 1), on “maintenance of hysteroscopy equipment” (chapter 2), on “imaging of the uterus” (chapter 4) and on “transcervical embryoscopy” (chapter 16). The book is well written. It has a distinguished Spanish authorship, and includes two chapters by two well known non-Spanish authors: B. Van Herendael and R. Valle a pioneer in operative hysteroscopy. The book is practical and well illustrated. I am certain that it will prove to be a valuable text for residents in gynecology and practicing gynecologists.
Professor Victor Gomel
Department of Obstetrics and Gynecology
Faculty of Medicine, University of British Columbia
Vancouver BC, Canada
11Preface
The aim of this book is to critically review different aspects of hysteroscopy with recognized experts from the United States and Europe. The main objective is to provide a balanced view of current clinical opinion and to review the rapidly expanding world of hysteroscopy.
Since the pioneer clinical work performed in the late seventies and up until a few years ago when hysteroscopy found its own in the field of Gynecology, the use of this technique has broadly expanded. We have been performing diagnostic hysteroscopy since the late eighties and surgical hysteroscopy since the early nineties. Today it has become the standard of reference for both diagnostic and therapeutic purposes for most pathology located in the uterine cavity. New fields of application of this technique are constantly being created.
This book begins with an extensive review of the anatomy, histology, physiology, and pathology of the endocervix and uterine cavity. Then the role of the OR nurse and personnel is outlined setting out disinfection and sterilization guidelines of the different elements of the hysteroscopy.
Evaluation of the uterine cavity is necessary when abnormal uterine haemorrhage occurs or when the fertility is being studied. Since the endometrium evolves constantly and cyclically under the influence of the sex hormones, its structure and thickness also change. When dishomogenic growth appears, it is mandatory to thoroughly assess those problems especially those that predispose the patient to malignant transformation of the lesion.
As with what happened with gynaecological laparoscopy a few years ago, hysteroscopy is no longer conceived of uniquely as a diagnostic procedure. The access to microsurgical instruments that can be inserted by accessory sheaths and the development of liquid continuous flow has transformed ambulatory hysteroscopy into a diagnostic and an operating procedure. A small number of selected intrauterine operations and in most cases without the need of anesthesia, can be performed at the same time as diagnosis, following the “see and treat” principle. Thus hysteroscopy may now be included in the concept of ambulatory surgery.
Hysteroscopy offers direct vision of the uterine cavity and the possibility to perform directed biopsies of suspicious areas. There are special hysteroscopes that evaluate lesions to different degrees and some even reach the nucleus-cytoplasm level. Other benign alterations like endometrial polyps or submucous fibromyomas can also produce pathological conditions that require treatment. Chapter 5 is devoted to different image methods that can be used as screening tests (TVUS, HSSG) or as an aid to define diagnosis (MRI).
When surgery is recommended, understanding the principles of electricity is essential. The specific anesthesia required for each technique is also outlined.
For endometrial ablation, the explanations in this book are limited to hysteroscopy and not to other techniques. There has been worldwide interest in a simple surgical alternative to abdominal or vaginal hysterectomy. High tech is involved in endometrial ablation by hysteroscopy and because the use of video cameras is needed, surgeons must retrain to master new surgical skills. Ablation should be considered in women whose only alternative would be hysterectomy due to heavy bleeding which causes anaemia and limits social activity. If patients are carefully selected, an annual recurrence rate of only 5 or 8% in the first four years is reported. This is an acceptable rate especially when ablation is performed in perimenopausal women. It is important to note that endometrial ablation 12is a proven, safe technique that allows the resolution of the problem in 3 out of 4 patients. It is important to acquire the know-how and to offer this solution to patients.
Finally, there are several genital tract malformations in which hysteroscopy is an effective method of diagnosis and treatment when infertility is evaluated. In the field of reproduction, synechiolysis or septolysis are well-known applications. Salpingoscopy, tubal cannulation, or hysteroscopic sterilization are examples of how this technique is continuously growing.
Embryoscopy is a technique where the embryo is directly observed. It has great potential in the future for example performing hysteroscopy-directed chorionic villous sampling or embryo biopsies when genetic alterations are suspected. These could be amongst the many possible applications we might see in the future.
Long-term complication rates are not available as yet. The experience of individual surgeons is relatively small, but it is hoped that national surveys will soon be published to provide a database from which the potential complications can be calculated. Although it is a safe technique, hysteroscopy is not problem-free, so it will be important for its future to be able to assess with precision the possible incidents that may occur and be prepared to resolve them.
National and international laparoscopic and hysteroscopic societies have been founded by enthusiastic practitioners. These physicians organize meetings and training courses. The future of hysteroscopy is brilliant and many new frontiers will be able to be explored with creative, skilled and well-trained physicians—this is a task in which all of us must participate.
Tirso Pérez-Medina
Enrique Cayuela Font